Part 32

§ 8. The Revolution in Surgery.

This history of antiseptic surgery is inseparably linked with the name of Lord Lister (1827-1912), whose work naturally dovetails into that of Pasteur. Lister’s attention was first called to the work of Pasteur in 1865. But Pasteur’s views on the life of micro-organisms came to a mind that had been prepared for them. Lister had had, moreover, a long and varied surgical experience and had been present at the first operation performed in England under Ether anaesthesia in 1846.

At that time and for long after, Surgery was cursed by the constant fear of sepsis. A vast amount of death and suffering was due to this cause, and surgeons were reluctant to perform many operations that we should now regard as trivial. Lister’s first attempt to make any scientific analysis of the septic state is to be found in a paper by him on The Early Stages of Inflammation (1853). He showed that the effects of irritation on the tissues are twofold. Firstly, there is a dilatation of the arteries which is developed through the nervous system. Secondly, there is an alteration in the tissues on which the irritant acts directly. This alteration imparted, as Lister thought, an adhesiveness to both the red and the white corpuscles, making them prone to stick to one another and to the walls of the vessels, and so giving rise to stagnation of blood and ultimately to obstruction.

Some years before (1847) A. V. Waller (1816-1870), a pupil of Magendie, had shown that during the process of inflammation there is an active migration of white blood corpuscles through the walls of the capillary blood-vessels. Waller’s observations attracted but little attention at the time. They were, however, amply confirmed in 1878 and the following years by the German pathologist Julius Cohnheim (1839-84), a pupil of Virchow. Cohnheim showed that this process of migration of white blood corpuscles is the essence of inflammation and that when inflammation goes on to suppuration the pus that is formed consists largely of white blood corpuscles in a dead and disintegrating state.

Irritation, and the reaction of the body against it, ‘inflammation’, are encountered in all injuries in which the healing is not direct and healthy. It was those cases of injury in which the healing was indirect and unhealthy which then formed the surgeon’s chief problem. Of these there are a variety, now rare, then very common and fatal, as Blood-Poisoning, Erysipelas, Pyaemia, Septicaemia, Hospital Gangrene, and that form, then so common as to be almost normal, simple suppuration of a wound.

About 1861 Lister began to teach publicly that the occurrence of suppuration in a wound is determined ‘simply by the influence of decomposition’. The nature of decomposition was revealed to him by the writings of Pasteur. From him he learned that putrefaction was, in fact, a fermentation, and that it was caused by the growth of minute microscopic organisms borne by the air. It was generally supposed that air was the cause of sepsis, and precautions were taken to exclude it from wounds. But Lister now saw that not air but that which it carried was the mischief-maker.

The general course of action was now clear to him. As a laboratory proposition the destruction of the organisms of the air was simple. The problem was to exclude them from wounds during and after operation. The solution of that problem developed as ‘Antiseptic Surgery’, which later became ‘Aseptic Surgery’. At first he paid most attention to air, as the source of infection. He recognized, however, that he must also deal with the germs present in the wound and on his hands. Of the methods available for ridding the air of its germs, viz. heat, filtration, and chemical action, he chose the last.

At that time carbolic acid was in use as a means of treating sewage. At first, therefore, Lister tried lint soaked in crude carbolic. This he found liable to cause superficial sloughing and death of the tissues. He next obtained a purer acid, using a solution in oil. A putty formed of common whitening and a solution of carbolic acid in linseed oil was used as a dressing. He adopted later a system of spraying the part during operation (Fig. 109).

FIG. 109. THE ‘DONKEY ENGINE’, an apparatus designed and used by Lord Lister to maintain a carbolic spray over a part during operation. The engine is worked by the up and down movement of the handle to the right and the spray is delivered through the tube to the left.

When Lister began his work, amputation of a limb was a very fatal operation. Yet it had to be performed in most cases of severe fracture in which the bone was exposed because, without it, death from sepsis was almost certain. The improvement in Lister’s own records of amputation, incident upon his adoption of the antiseptic method, is well brought out by his own figures:

Years. Cases. Recovered. Died. Mortality. 1864-66 35 19 16 43% without antiseptics 1867-70 40 34 6 15% with antiseptics

These results were considered extraordinarily good in their day. It is an index of the further advance since Lister’s first attempts that results ten times as good would now be regarded as unsatisfactory. Moreover not only has the further development of Lister’s method rendered amputation safer, but also it has enabled the surgeon to treat many cases without amputation, when before he would have been compelled to resort to that measure.

Lister first recorded his observations on the antiseptic system of surgery in 1867. Apart from the technical advances that he then set forth, he recorded also many new pathological facts that have since proved of great practical importance. Thus he showed that an uninfected clot, if undisturbed, can become organized into a living tissue, and that a piece of dead bone may be absorbed in an aseptic wound. These are now matters of common knowledge, but then they were instrumental in introducing a radically new outlook.

Lister gradually perfected his technique, chiefly in the direction of using milder antiseptics and adopting heat for the sterilization of instruments and dressings. The antiseptic system was given its military application in France during the war of 1870. It was soon taken up also by German surgeons. The history of surgery since Lister’s day has been very often told. An important element in it is the gradual supersession of ‘antiseptic’ by ‘aseptic’ methods (p. 248).

The Listerian system, in rendering surgery safer, had also the effect of opening up many fields of operation that had previously been regarded as impracticable. Especially is this the case with abdominal surgery, which effectively dates from the introduction of the antiseptic system. Lister was often misunderstood and some of his contemporaries, and some even of those who opposed him, were really practising his system without knowing it.

Among the most important reactions of antiseptic surgery was that upon the conduct of labor. Here Lister had a predecessor, as he gladly and generously acknowledged. This was the unfortunate and almost insane Viennese genius, Ignaz Semmelweis (1818-65). At the great lying-in hospital at Vienna in which he was an assistant the death-rate at one time rose to thirty per cent., the so-called ‘puerperal fever’ being the active cause. The women were attended by students or physicians who were visiting the post-mortem room. Semmelweis showed that the infective material that conveyed the fever was brought by the hands of the operator from the dead bodies and he showed that puerperal fever was caused by decomposed animal matter. By insisting on the hands of the operators being sterilized, Semmelweis succeeded in 1846 in enormously reducing the mortality. After the acceptance of Lister’s antiseptic system the methods of Semmelweis were universally introduced into the practice of Midwifery. Another predecessor of Lister was Oliver Wendell Holmes. As early as 1843 he pointed out that the mysterious ‘puerperal fever’ was contagious, and carried by the hands of the operator. He suggested precautions not dissimilar to those of Semmelweis.

§ 9. Some Modern Surgical Advances.

Among the most capable surgeons of Lister’s own day was Thomas Spencer Wells (1818-97) of London. This great operator had been opening the abdomen successfully for certain conditions since 1858. By 1867 his methods were approaching the Listerian. Under Lister’s inspiration he further improved his technique and did more than any other man to raise the possibilities of abdominal surgery. Spencer Wells stands out for the extreme simplicity, directness, and effectiveness of his methods (Fig. 111), and for his exceptionally conscientious care as an operator. His name is commonly attached to an instrument of his invention of catching the bleeding ends of cut blood-vessels. The familiar ‘Spencer Wells forceps’ is at this day probably more frequently used than any other surgical instrument (Fig. 110).

FIG. 111. SPENCER WELLS performing an abdominal operation about 1870. The picture illustrates the extreme simplicity of the methods of this great surgeon. It also shows a method of administering chloroform. Air is pumped through a bottle into a mask held at a variable distance from the face of the patient.

Since the time of Lister many branches of Science have contributed to the development of surgical technique. No addition to the surgical armory has, however, been more important than that made by the physicist Wilhelm Conrad Röntgen (1845-1923). In 1895 he found that when an electric discharge passes through a high vacuum rays are emitted that are far more penetrating than ordinary light. These rays have since then been placed in series with light rays, ultra-violet rays and infra-red rays, and it has been shown that they differ from these only in their wave-length. The surgical application of the Röntgen or X-rays was at once made to the examination of bone. Since then the more accurate knowledge of the properties of these rays has made them of value in exploring almost every organ of the body. Radiography is now constantly applied in the diagnosis of medical and surgical conditions of the organs of the chest and abdomen.

The more dramatic achievements of modern surgery, the drastic operations that surgeons are now able to perform on the great cavities of the body--head, chest, and abdomen--have attracted much public attention. Nevertheless few surgical advances have relieved so much suffering and disability as the unsensational development in the treatment of fractures.

After the advent of Listerian methods the technique of the treatment of compound fractures was gradually perfected. Simple fractures--which are far commoner--continued, however, to be treated with splints in the traditional fashion. Plaster of Paris bandages, which came into wide use in the ’seventies, were some improvement; but prolonged immobilization of a limb, in either splints or plaster bandages, always involves much subsequent pain and stiffness, lasting, at best, for months. To obviate this, Massage--a practice of immemorial antiquity in Folk Medicine--had been introduced into Surgery in the sixteenth century by Ambroise Paré (pp. 92-94). The subject was little heard of till the last thirty years of the nineteenth century. The pioneer was the Dutch surgeon Johann Mezger (1839-1900), through whom some scientific advance was made.

The semi-conscious patient lies face downward on an elaborately carved bed. The bearded surgeon, dressed in his ordinary clothes, is trephining his skull and is rotating the trephine between his hands. Against the side of the bed lounges a gallant to whom a servant brings refreshment. In the background are two women assistants. A male assistant is spreading a plaster and another warming a towel over a brazier. Note that all present, surgeon, nurses, assistants, &c., wear their ordinary dress. No arrangements are made for washing. In the foreground is a cat playing with a mouse. ]

The introduction of X-rays into Surgery made for very accurate diagnosis of the state of fractures. It has thus gradually become possible to treat a large proportion of these injuries without immobilization either by splints or plaster. In many cases the injured limb is merely held in correct position between sandbags and massage used from the first. Much stiffness and disability is thereby avoided and the length of the period of treatment greatly shortened. The rise of a class of scientifically trained Masseurs has made possible a wider application of this valuable curative procedure.

Improvements in methods of operation have been very numerous during the last generation. Many can be appreciated only by those with technical knowledge. In 1886 Ernst von Bergmann of Berlin (1836-1907) introduced steam sterilization of dressings and thus moved toward the replacement of antiseptic by aseptic methods. W. S. Halsted, then of New York, had been working to the same end. In 1890, finding it impossible to sterilize the hands completely, he introduced the rubber gloves now universally employed by surgeons during operations. Much important work in experimental surgery has been done by Alexis Carrel of New York (1873-) and some of his laboratory methods have become available in surgical practice. The technique of abdominal surgery has been greatly advanced by many workers, important among whom are J. B. Murphy (1857-1916) of Chicago and the brothers Charles and William Mayo (1865 and 1861) of Rochester, Minnesota. The surgery of the brain was prosecuted in England by Rickman Godlee (1849-1925), the nephew and biographer of Lister, by Victor Horsley (1857-1916), and above all by William Macewen (1848-1926), a successor to Lister’s chair at Glasgow and one of the finest exponents of Listerian methods. The surgery of the nervous system in general, and that of the brain in particular, has been carried to extraordinary refinements in America by Harvey Cushing. There can be no doubt that during the twentieth century advances in Surgery have been more important and more numerous in the United States than in any other country.

Only those directly concerned with the operation are present in the room. All wear aseptic clothes and aseptic rubber gloves. Every source of infection is guarded against and all breathe through masks. The patient is covered by aseptic cloths and only the part operated on is exposed.

§ 10. Bacteriology becomes a special Science.

We have seen the microbic view of the origin of disease demonstrated as a reality by Pasteur (pp. 224-35) and extended to special disease conditions by him and by Koch (pp. 229-32). While the French observer stood above all men for the clearness and steadiness of his vision and for his persistence and resource in following what he had seen from afar, his German colleague had a genius for visualizing particulars and for adapting mechanical devices and scientific discoveries to particular ends. Koch thus vastly improved and elaborated the methods for detecting and examining minute organisms. The significance of his results was at once recognized, but the complexity of the technique involved and the time and training necessary demanded the elevation of the subject into the position of a special science.